Originating Committee Review Council Adopted

REFERENCE MANUAL
V 35 / NO 6
13 / 14
Guideline on Periodicity of Examination, Preventive
Dental Services, Anticipatory Guidance/Counseling, and
Oral Treatment for Infants, Children, and Adolescents
Originating Committee
Clinical Affairs Committee
Review Council
Council on Clinical Affairs
Adopted
1991
Revised
1992, 1996, 2000, 2003, 2007, 2009, 2013
Purpose
The American Academy of Pediatric Dentistry (AAPD) intends
this guideline to help practitioners make clinical decisions
concerning preventive oral health interventions, including
anticipatory guidance and preventive counseling, for infants,
children, and adolescents.
Methods
This guideline is an update of a document previously revised
in 2009. The update used electronic database and hand searches
of articles in the medical and dental literature using the following parameters: Terms: “periodicity of dental examinations”,
“dental recall intervals”, “preventive dental services”, “anticipatory guidance and dentistry”, “caries risk assessment”, “early
childhood caries”, “dental caries prediction”, “dental care cost
effectiveness children”, “periodontal disease and children and
adolescents US”, “pit and fissure sealants”, “dental sealants“,
“fluoride supplementation and topical fluoride”, “dental trauma”, “dental fracture and tooth”, “nonnutritive oral habits”,
“treatment of developing malocclusion”, “removal of wisdom
teeth”, “removal of third molars”; Fields: all; Limits: within
the last 10 years, humans, English, and clinical trials; birth
through age 18. From this search, 3,418 articles matched these
criteria and were evaluated by title and/or abstract. Information from 113 articles was chosen for review to update this
document. When data did not appear sufficient or were
inconclusive, recommendations were based upon expert and/
or consensus opinion by experienced researchers and clinicians.
Background
Professional dental care is necessary to maintain oral health.1,2
The AAPD emphasizes the importance of initiating professional oral health intervention in infancy and continuing
through adolescence and beyond.1-3 The periodicity of professional oral health intervention and services is based on a
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patient’s individual needs and risk indicators.4-7 Each age
group, as well as each individual child, has distinct developmental needs to be addressed at specific intervals as part of a
comprehensive evaluation.8-11 Continuity of care is based on
the assessed needs of the individual patient and assures appropriate management of all oral conditions, dental disease, and
injuries.12-18 The early dental visit to establish a dental home
provides a foundation upon which a lifetime of preventive
education and oral health care can be built.19-21 Anticipatory
guidance and counseling are essential components of the
dental visit.8-10,19-26
Recommendations
This guideline addresses periodicity and general principles of
examination, preventive dental services, anticipatory guidance/
counseling, and oral treatment for children who have no
contributory medical conditions and are developing normally.
An accurate, comprehensive, and up-to-date medical history is
necessary for correct diagnosis and effective treatment planning. Recommendations may be modified to meet the unique
requirements of patients with special health care needs.
Clinical oral examination
The first examination is recommended at the time of the
eruption of the first tooth and no later than 12 months of
age.19-21 The developing dentition and occlusion should be monitored throughout eruption at regular clinical examinations.26
Early detection and management of oral conditions can improve a child’s oral health, general health and well-being, and
school readiness.22,28-31 Delayed diagnosis of dental disease can
result in exacerbated problems which lead to more extensive
and costly care.7,28,32-35 Early diagnosis of developing malocclusions may allow for timely therapeutic intervention.9,26
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
Components of a comprehensive oral examination include
assessment of:
• General health/growth
• Pain • Extraoral soft tissue
• Temporomandibular joint
• Intraoral soft tissue
• Oral hygiene and periodontal health
• Intraoral hard tissue
• Developing occlusion
• Caries risk
• Behavior of child
Based upon the visual examination, the dentist may employ additional diagnostic aids (eg, radiographs, photographs,
pulp vitality testing, laboratory tests, study casts).7,36
The most common interval of examination is six months;
however, some patients may require examination and preventive services at more or less frequent intervals, based upon
historical, clinical, and radiographic findings.5,7,16-18,37-42 Caries
and its sequelae are among the most prevalent health problems facing infants, children, and adolescents in America.1,43
Carious lesions are cumulative and progressive and, in the
primary dentition, are highly predictive of caries occurring in
the permanent dentition.44-46 Reevaluation and reinforcement of
preventive activities contribute to improved instruction for the
caregiver of the child or adolescent, continuity of evaluation
of the patient’s health status, and repetitive exposure to dental
procedures, potentially allaying anxiety and fear for the
apprehensive child or adolescent.47
Caries-risk assessment
Risk assessment is a key element of contemporary preventive
care for infants, children, adolescents, and persons with special
health care needs. Its goal is to prevent disease by identifying
and minimizing causative factors (eg, microbial burden, dietary
habits, plaque accumulation) and optimizing protective factors (eg, fluoride exposure, oral hygiene, sealants).48 Caries risk
assessment forms and management protocols simplify and
clarify the process.24,49,50
Sufficient evidence demonstrates certain groups of children
at greater risk for development of early childhood caries
(ECC) would benefit from infant oral health care. 22,28,51-53
Infants and young children have unique caries-risk factors
such as ongoing establishment of oral flora and host defense
systems, susceptibility of newly erupted teeth, and development of dietary habits. Children are most likely to develop
caries if mutans streptococci are acquired at an early age. 51,54
The characteristics of ECC and the availability of preventive
approaches support age-based strategies in addressing this
significant pediatric health problem.54 ECC can be a costly,
devastating disease with lasting detrimental effects on the
dentition and systemic health.22,28-35
Adolescence can be a time of heightened caries activity
due to an increased intake of cariogenic substances and
inattention to oral hygiene procedures. 9,55,56 Risk assessment
can assure preventive care is tailored to each individual’s
needs and direct resources to those for whom preventive
interventions provide the greatest benefit. Because a child’s
risk for developing dental disease can change over time
due to changes in habits (eg, diet, home care), oral microflora, or physical condition, risk assessment must be
documented and repeated regularly and frequently to maximize effectiveness.11,23
Prophylaxis and topical fluoride treatment
The interval for frequency of professional preventive services
is based upon assessed risk for caries and periodontal disease.4,5,7,11,23,37,49-51 Gingivitis is nearly universal in children and
adolescents41; it usually responds to thorough removal of bacterial deposits and improved oral hygiene. 41,57,58 Hormonal
fluctuations, including those occurring during the onset of
puberty, can modify the gingival inflammatory response to
dental plaque. 41,42 Children can develop any of the several
forms of periodontitis, with aggressive periodontitis occurring
more commonly in children and adolescents than adults.41.42,58
Caries risk may change quickly during active dental eruption phases. Newly erupted teeth may be at higher risk of
developing caries, especially during the post-eruption maturation process. Children who exhibit higher risk of developing
caries would benefit from recall appointments at greater
frequency than every six months.4,5,7,11,23,50 This allows increased
professional fluoride therapy application, microbial monitoring, antimicrobial therapy reapplication, and reevaluating
behavioral changes for effectiveness.50,59,60 An individualized
preventive plan increases the probability of good oral health
by demonstrating proper oral hygiene methods/techniques
and removing plaque, stain, and calculus.4,42,61
Professional topical fluoride treatments should be based
on caries risk assessment.23,24,62-64 Plaque and pellicle are not a
barrier to fluoride uptake in enamel.65-67 Consequently, there
is no evidence of a difference in caries rates or fluoride uptake
in patients who receive rubber cup prophylaxis or a toothbrush prophylaxis before fluoride treatment.65,66 Precautionary
measures should be taken to prevent swallowing of any professionally-applied topical fluoride. Children at moderate caries
risk should receive a professional fluoride treatment at least
every six months; those with high caries risk should receive
greater frequency of professional fluoride applications (eg,
every three to six months).63,67-72 Ideally, this would occur as
part of a comprehensive preventive program in a dental home.19
Fluoride supplementation
Fluoride contributes to the prevention, inhibition, and reversal
of caries.64,72-74 The AAPD encourages optimal fluoride exposure for every child, recognizing fluoride in the community
water supplies as the most beneficial and cost-effective preventive intervention. Fluoride supplementation should be
considered for children at moderate to high caries risk when
fluoride exposure is not optimal.72 Supplementation should
be in accordance with the guidelines recommended by the
AAPD72 and the American Dental Association (ADA)75.
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Anticipatory guidance/counseling
Anticipatory guidance is the process of providing practical,
developmentally-appropriate information about children’s
health to prepare parents for the significant physical, emotional, and psychological milestones. 8,9,19,20,76 Individualized
discussion and counseling should be an integral part of each
visit. Topics to be included are oral hygiene and dietary habits,
injury prevention, nonnutritive habits, substance abuse,
intraoral/perioral piercing, and speech/language development.8,9,15,19,20,26,76-80
Oral hygiene counseling involves the parent and patient.
Initially, oral hygiene is the responsibility of the parent. As the
child develops, home care is performed jointly by parent and
child. When a child demonstrates the understanding and ability to perform personal hygiene techniques, the health care
professional should counsel the child. The effectiveness of
home care should be monitored at every visit and includes a
discussion on the consistency of daily preventive activities.4,5,9,23
Caries-conducive dietary practices appear to be established
early, probably by 12 months of age, and are maintained
throughout early childhood.81-83 Dietary practices, including
prolonged and/or frequent bottle or training cup with sugarcontaining drinks and frequent between-meal consumption
of sugar-containing snacks or drinks (eg, juice, formula, soda),
increase the risk of caries. 83,84 The role of carbohydrates in
caries initiation is unequivocal. Acids in carbonated beverages
and sports drinks can have a deleterious effect (ie, erosion) on
enamel.85-87 Excess consumption of carbohydrates, fats, and
sodium contribute to poor systemic health.88-90 Dietary analysis and the role of dietary choices on oral health, malnutrition, and obesity should be addressed through nutritional and
preventive oral health counseling at periodic visits. 25 The US
Department of Agriculture’s Food Plate 91 and Center for
Disease Control and Prevention/National Center for Health
Statistics’ Growth Charts92 provide guidance for parents and
their children and promote better understanding of the
relationship between healthy diet and development.
Facial trauma that results in fractured, displaced, or lost
teeth can have significant negative functional, esthetic, and
psychological effects on children. 93 Practitioners should provide age-appropriate injury prevention counseling for orofacial
trauma.15,76 Initially, discussions would include advice regarding play objects, pacifiers, car seats, and electrical cords. As
motor coordination develops, the parent/patient should be
counseled on additional safety and preventive measures, including use of athletic mouthguards for sporting activities.
The greatest incidence of trauma to the primary dentition
occurs at two to three years of age, a time of increased mobility
and developing coordination.94 The most common injuries to
permanent teeth occur secondary to falls, followed by traffic
accidents, violence, and sports. 95-98 Dental injuries could
have improved outcomes if the public were aware of first-aid
measures and the need to seek immediate treatment.
Nonnutritive oral habits (eg, digital and pacifier habits,
bruxism, abnormal tongue thrusts) may apply forces to teeth
and dentoalveolar structures.26 Although early use of pacifiers
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CLINICAL GUIDELINES
and digit sucking are considered normal, habits of sufficient
frequency, intensity, and duration can contribute to deleterious
changes in occlusion and facial development.26 It is important to discuss the need for early pacifier and digit sucking,
then the need to wean from the habits before malocclusion
or skeletal dysplasias occur.26 Early dental visits provide an
opportunity to encourage parents to help their children stop
sucking habits by age three years or younger. For school-aged
children and adolescent patients, counseling regarding any
existing habits (eg, fingernail biting, clenching, bruxism) is
appropriate.26
Speech and language are integral components of a child’s
early development. 80 Deficiencies and abnormal delays in
speech and language production can be recognized early and
referral made to address these concerns. Communication and
coordination of appliance therapy with a speech and language
professional can assist in the timely treatment of speech disorders.80
Smoking and smokeless tobacco use almost always are initiated and established in adolescence.99-101 During this time
period, children may be exposed to opportunities to experiment with other substances that negatively impact their health
and well-being. Practitioners should provide education regarding the serious health consequences of tobacco use and
exposure to second hand smoke. 78,100 The practitioner may
need to obtain information regarding tobacco use and alcohol/
drug abuse confidentially from an adolescent patient.9 When
substance abuse has been identified, referral for appropriate
intervention is indicated.78
Complications from intraoral/perioral piercings can range
from pain, infection, and tooth fracture to life-threatening
conditions of bleeding, edema, and airway obstruction.79 Although piercings most commonly are observed in the teenaged pediatric dental patient, education regarding pathologic
conditions and sequelae associated with these piercings should
be initiated for the preteen child/parent and reinforced during
subsequent periodic visits.79
Radiographic assessment
Appropriate radiographs are a valuable adjunct in the oral
health care of infants, children, and adolescents.38,39 Timing of
initial radiographic examination should not be based on the
patient’s age.39 Rather, after review of an individual’s history
and clinical findings, judicious determination of radiographic
needs and examination can optimize patient care while minimizing radiation exposure. 38,39 The US Food and Drug
Administration/ADA guidelines were developed to assist the
dentist in deciding under what circumstances specific radiographs are indicated.39
Treatment of dental disease/injury
Healthcare providers who diagnose oral disease or trauma
should either provide therapy or refer the patient to an
appropriately-trained individual for treatment.103 Immediate
intervention is necessary to prevent further dental destruction, as well as more widespread health problems. Postponed
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
treatment can result in exacerbated problems that may lead to
the need for more extensive care.21,2930,,34 Early intervention
could result in savings of healthcare dollars for individuals,
community health care programs, and third party payors.21,29,30,34
Treatment of developing malocclusion
Guidance of eruption and development of the primary, mixed,
and permanent dentitions is an integral component of comprehensive oral health care for all pediatric dental patients.26
Early diagnosis and successful treatment of developing malocclusions can have both short-term and long-term benefits,
while achieving the goals of occlusal harmony and function
and dentofacial esthestics.104-108 Early treatment is beneficial for
many patients, but is not indicated for every patient. When
there is a reasonable indication that an oral habit will result in
unfavorable sequelae in the developing permanent dentition,
any treatment must be appropriate for the child’s development, comprehension, and ability to cooperate. Use of an
appliance is indicated only when the child wants to stop the
habit and would benefit from a reminder.26 At each stage of
occlusal development, the objectives of intervention/treatment
include: (1) reversing adverse growth, (2) preventing dental
and skeletal disharmonies, (3) improving esthetics of the smile,
(4) improving self-image, and (5) improving the occlusion.26
Sealants
Sealants reduce the risk of pit and fissure caries in susceptible
teeth and are cost-effective when maintained. 109-113 They are
indicated for primary and permanent teeth with pits and fissures that are predisposed to plaque retention.112 At-risk pits
and fissures should be sealed as soon as possible. Because caries
risk may increase at any time during a patient’s life due to
changes in habits (eg, dietary, home care), oral microflora, or
physical condition, unsealed teeth subsequently might benefit
from sealant application.109,114 The need for sealant placement
should be reassessed at periodic preventive care appointments.
Sealants should be monitored and repaired or replaced as
needed.111,112,114
Third molars
Panoramic or periapical radiographic assessment is indicated
during late adolescence to assess the presence, position, and development of third molars.38,39 A decision to remove or retain
third molars should be made before the middle of the third
decade.115 Impacted third molars are potentially pathologic.
Pathologic conditions generally are more common with an
increase in age. Evaluation and treatment may require removal,
exposure, and/or repositioning. In selected cases, long-term
monitoring may be needed. Treatment should be provided before pathologic conditions adversely affect the patient’s oral
and/or systemic health.108,115,116 Consideration should be given
to removal when there is a high probability of disease or pathology and/or the risks associated with early removal are less
than the risks of later removal.14,108,116 Postoperative complications for removal of impacted third molars are low when
performed at an early age. A Cochrane review in 2012 reported
there was no difference in late lower incisor crowding with
removal or retention of asymptomatic impacted third molars.117
Referral for regular and periodic dental care
As adolescent patients approach the age of majority, it is
important to educate the patient and parent on the value of
transitioning to a dentist who is knowledgeable in adult oral
health care. At the time agreed upon by the patient, parent,
and pediatric dentist, the patient should be referred to a specific practitioner in an environment sensitive to the adolescent’s individual needs. 9,27 Until the new dental home is
established, the patient should maintain a relationship with the
current care provider and have access to emergency services.
Proper communication and records transfer allow for consistent
and continuous care for the patient.36
Recommendations by age
6 to 12 months
1. Complete the clinical oral examination with adjunctive
diagnostic tools (eg, radiographs as determined by child’s
history, clinical findings, and susceptibility to oral disease)
to assess oral growth and development, pathology, and/or
injuries; provide diagnosis.
2. Provide oral hygiene counseling for parents, including the
implications of the oral health of the caregiver.
3. Remove supragingival and subgingival stains or deposits
as indicated.
4.Assess the child’s systemic and topical fluoride status
(including type of infant formula used, if any, and exposure
to fluoridated toothpaste) and provide counseling regarding fluoride. Prescribe systemic fluoride supplements, if
indicated, following assessment of total fluoride intake
from drinking water, diet, and oral hygiene products.
5. Assess appropriateness of feeding practices, including bottle and breast-feeding, and provide counseling as indicated.
6. Provide dietary counseling related to oral health.
7. Provide age-appropriate injury prevention counseling for
orofacial trauma.
8. Provide counseling for nonnutritive oral habits (eg, digit,
pacifiers).
9. Provide required treatment and/or appropriate referral for
any oral diseases or injuries.
10. Provide anticipatory guidance.
11. Consult with the child’s physician as needed.
12. Complete a caries risk assessment.
13. Determine the interval for periodic reevaluation.
12 to 24 months
1. Repeat the procedures for ages 6 to 12 months every six
months or as indicated by individual patient’s risk status/
susceptibility to disease.
2.Assess appropriateness of feeding practices (including
bottle, breast-feeding, and no-spill training cups) and
provide counseling as indicated.
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3. Review patient’s fluoride status (including any childcare
arrangements which may impact systemic fluoride
intake) and provide parental counseling.
4. Provide topical fluoride treatments every six months or
as indicated by the individual patient’s needs.
2 to 6 years
1. Repeat the procedures for 12 to 24 months every six
months or as indicated by individual patient’s risk status/
susceptibility to disease. Provide age-appropriate oral
hygiene instructions.
2. Scale and clean the teeth every six months or as indicated by individual patient’s needs.
3.Provide pit and fissure sealants for caries-susceptible
primary molars and permanent molars, premolars, and
anterior teeth.
4.Provide counseling and services (eg, mouthguards) as
needed for orofacial trauma prevention.
5.Provide assessment/treatment or referral of developing
malocclusion as indicated by individual patient’s needs.
6. Provide required treatment and/or appropriate referral for
any oral diseases, habits, or injuries as indicated.
7.Assess speech and language development and provide
appropriate referral as indicated.
6 to 12 years
1. Repeat the procedures for ages two to six years every six
months or as indicated by individual patient’s risk
status/susceptibility to disease.
2. Provide substance abuse counseling (eg, smoking, smokeless tobacco).
3. Provide counseling on intraoral/perioral piercing.
12 years and older
1. Repeat the procedures for ages six to 12 years every six
months or as indicated by individual patient’s risk status/
susceptibility to disease.
2. During late adolescence, assess the presence, position, and
development of third molars, giving consideration to removal when there is a high probability of disease or
pathology and/or the risks associated with early removal
are less than the risks of later removal.
3. At an age determined by patient, parent, and pediatric
dentist, refer the patient to a general dentist for continuing oral care.
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122
CLINICAL GUIDELINES
•
•
•
Radiographic assessment
Prophylaxis and topical fluoride
•
Parent
•
•
•
•
7
8
9
10
10
Anticipatory guidance/counseling
Oral hygiene counseling
Dietary counseling
Injury prevention counseling
Counseling for nonnutritive habits
Counseling for speech/language development
7 Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child.
6 Appropriate discussion and counseling should be an integral part of each visit for care.
5 Consider when systemic fluoride exposure is suboptimal. Up to at least 16 years.
4 Timing, selection, and frequency determined by child’s history, clinical findings, and susceptibility to oral disease.
11 For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep
pits and fissures; placed as soon as possible after eruption.
10 At first, discuss the need for additional sucking: digits vs pacifiers; then the need to wean from the
habit before malocclusion or skeletal dysplasia occurs. For school-aged children and adolescent
patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism.
9 Initially play objects, pacifiers, car seats; when learning to walk; then with sports and routine playing,
including the importance of mouthguards.
2 By clinical examination.
3 Must be repeated regularly and frequently to maximize effectiveness.
8 At every appointment; initially discuss appropriate feeding practices, then the role of refined
carbohydrates and frequency of snacking in caries development and childhood obesity.
10
1 First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as
indicated by child’s risk status/susceptibility to disease. Includes assessment of pathology and injuries.
Transition to adult dental care
Assessment and/or removal of third molars
•
•
•
•
Counseling for intraoral/perioral piercing
Assessment for pit and fissure sealants 1
•
•
•
•
•
Patient
•
•
•
•
•
Patient/parent
•
•
•
•
•
•
•
12 YEARS
AND OLDER
Substance abuse counseling
•
•
•
•
•
•
Patient/parent
•
•
•
•
•
•
•
6 TO 12 YEARS
•
•
•
Parent
•
•
•
•
•
•
•
2 TO 6 YEARS
•
110
•
•
6
Fluoride supplementation
Assessment and treatment of developing
malocclusion
•
•
5
•
•
•
3,4
Caries-risk assessment
•
•
•
20
40
•
•
1
3
Assess oral growth and development
12 TO 24 MONTHS
6 TO 12 MONTHS
AGE
V 35 / NO 6
Clinical oral examination
American Academy
of Pediatric Dentistry
Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric
Dentistry (AAPD) emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs of the child. Refer to the text
of this guideline for supporting information and references. Refer to the text in the Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance,
and Oral Treatment for Infants, Children, and Adolescents (www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf) for supporting information and references.
Recommendations for Pediatric Oral Health Assessment, Preventive Services,
and Anticipatory Guidance/Counseling
REFERENCE MANUAL
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